NCG210399_Name-Owner Change Form_4/15/2020

Action History (UTC-05:00) Eastern Time (US & Canada)
Subrrit by Anonymous User 4/15/2020 4:27:16 PM (Name Change Submission)
Approve by McCoy, Suzanne 4/17/2020 8:36:07 AM (Notification to Admin)
• The task was assigned to McCoy, Suzanne 4/15/2020 4:27 PM

NORTH CAROLINA
EmlmnmerrW Quality
I. Permit Information
I. Please enter the permit number for which the change is requested.
NPDES Stormwater Individual Permit #:
NC
SX
XX
XX
X
WTZIE
General Permit Certificate of Coverage (COC) #:
NCG210399
NC
GX
XX
XX
X
Use this link to check the permit contact information that is currently in our database.

II. Permit Status
11. Permit status prior to requested change.
a. Permit issued to: Southern Shavings
Conpany I brre
b. Person legally responsible for permit:
First name:* Middle name: Last name:*
TAYLOR J DAME
Title:
Permit holder's mailing address:* Street Address
300 NW 16th St
Address Line 2
City
State / Rovince / Fbgion
Fruitland
Idaho
Fbstal / Zip Code
Country
83619
United States
Phone #:*
Fax #:
20890
19637
c. Facility name:*
Woodgrain Millwork Dba Natures by Woodgrain
d. Facility address:*
Street Address
317 Jim Cline Road, Fallston NC 28042
Address Line 2
City State / Rovince / F;bgion
Fallston North Carolina
Fbstal / Zip Code Country
28042 United States
e. Facility contact person (prior to change, optional):
First name: Middle name: Last name:
Rocky Hullette
Phone #: [phone]

III. Requested Change Information
111. Please provide the following for the requested change (revised permit).
a. Request for changes is a result r Change in ownership of facility
of: * r Name Change of the facility or owner
b. Permit to be issued to:* Woodgrain Millwork Dba Natures by Woodgrain
Conpany fine
c. Person to be legally responsible for permit:
First name:* Middle name: Last name:*
TAYLOR J DAME
Title: Division Manager
Permit holder's mailing address:* Street Address
300 NW 16th St
Phone #:*
20890
19637
d. Faciltiyname:*
e. Facility address:*
Address Line 2
city
Fruitland
Postal / Zip Code
83619
Email address:*
tjdame@
woodgrai
n.com
State / Province / Region
Idaho
Country
United States
Woodgrain Millwork Dba Natures by Woodgrain
Street Address
317 Jim Cline Road
Address Line 2
City
Fallston
Postal / Zip Code
28042
Is the FACILITY contact different than the person legally responsible
above?*
r Yes
r No
f. Facility contact person:
First name:* Middle name: Last name:*
Rocky Hullette
Phone #:* 7046891515
Email address:* [e-mail]
State / Province / Region
NC
Country
Cleveland

IV. Permit Contact Information
Is the PERMIT contact different than the person legally responsible
above?*
r Yes
l: No

V. Permit Facility Activities
V. Will the permitted facility continue to conduct the SAME industrial activities conducted prior to this
ownership or name change:*
r Yes
No

VI. Signature
In the case of an ownership change request, certifications must be signed by both the permit holder
prior to the change and the new applicant. For a name change request, the signed Permittee's
Certification is sufficient.
This completed application is required for both name change and/or ownership change requests.
Legal documentation of transfer of ownership (such as relevant pages of a contract deed, or a bill of
sale) is required for an ownership change request. Articles of incorporation are not sufficient for an
ownership change.
File Upload:* Upload supporting documentation for ownership change
Executed APA 3-6-2020.pdf 892.14KB
pdf only
North Carolina General Statute 143 - 215.6 b (i) provides that:
Any person who knowingly makes any false statement, representation, or certification in any application, record, report, plan, or
other document filed or required to be maintained under this Article or a rule implementing this Article; or who knowingly makes a
false statement of a material fact in a rulemaking proceeding or contested case under this Article; or who falsifies, tampers with, or
knowingly renders inaccurate any recording or monitoring device or method required to be operated or maintained under this Article
or rules of the [Environmental Management] Commission implementing this Article shall be guilty of a Class 2 misdemeanor which
may include a fine not to exceed ten thousand dollars ($10,000).
Permittee Certification: I attest that this application for a name and/or ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not
completed, or if all required supporting information is not included, this application will be considered incomplete.
Permittee Signature
Perrrit-holder prior to the ownership change, or permit -holder authorizing the narre change
Applicant Certification: I attest that this application for a name and/or ownership change has been reviewed and is
accurate and complete to the best of my knowledge. I understand that if all required parts of this application are not
completed, or if all required supporting information is not included, this application will be considered incomplete.
Applicant Signature
To whom the permt is to be transferred
Will another person need to complete or sign this form before it can be submitted? No problem! Simply CLICK
the "Save as Draft" button below and send the URL link to the other party to access the form. Questions? Call The
Stormwater Program at [phone] or e-mail Annette Lucas at annette.lucas(@ncdenr.gov.

Initial Review
Project ID:* Pleviewer may revise permt nurrber here if incorrect.
NCG210399